psychology

Newcomer immigrant youth – refugees, asylum seekers, and unaccompanied children – face unique behavioral, social, and learning challenges as a result of trauma. Julian Ford recently co-authored A Trauma-Informed Approach to Judicial Decision-Making for Newcomer Immigrant Youth in Juvenile Justice Proceedings, a primer for juvenile court judges and advocates who encounter immigrant youth. We asked Ford how trauma impacts these children and what doctors should remember when treating them.

Newcomer immigrant youth – refugees, asylum seekers, and unaccompanied children – face unique behavioral, social, and learning challenges as a result of trauma. Julian Ford recently co-authored A Trauma-Informed Approach to Judicial Decision-Making for Newcomer Immigrant Youth in Juvenile Justice Proceedings, a primer for juvenile court judges and advocates who encounter immigrant youth. We asked Ford how trauma impacts these children and what doctors should remember when treating them.

They are impacted by violence in their countries of origin and on the journey to the U.S., as well as by race-related and institutional trauma in this country. Many develop a sense of fear, distrust, and even hopelessness that interferes with relationships, school, adjustment to new communities, and their physical health. These problems can persist for many years.

Q

What behaviors do they exhibit as a result?

These youth are often distrustful as a result of trauma, and can be very withdrawn or impulsive in an attempt to protect themselves from further trauma. This is a form of “survival coping,” which results from chronically not feeling safe. Justice involvement can occur when these youths feel that they must take extreme steps to protect themselves, which can lead to breaking rules — such as at school — or confrontations with law enforcement.

Q

How can physicians provide the best care to these patients?

Immigrant youths and their families, especially recent newcomers, have come to the United States in a period of turmoil and controversy that has heightened the stress they face in coming to a new country and new community. Many may feel reluctant to seek health care for fear of facing prejudice or discrimination. Providing a clear message of welcome and acceptance, in addition to showing interest in learning and respect for their culture and traditions, is essential to forging a positive treatment relationship — and can reduce patients’ anxieties and contribute to better health outcomes.

Expect that it will take some time, often several visits, for these youths and their families to feel sufficiently trusting and safe to fully and actively engage in dialogue and the treatment process. Patience and consistency on the part of the health care professional are a crucial counterbalance to the often harsh and even traumatic encounters many have had with putative helpers and institutional officials during their journey and once in the United States.

Explaining the nature and limits of confidentiality can help reduce fears about being subject to immigration sanctions.

Q

Is there a plan in place to help youths who suffer from this type of trauma?

The National Child Traumatic Stress Network has established more than 15 programs nationally for these youths. [The Center for Treatment of Developmental Trauma Disorders and The Center for Trauma Recovery and Juvenile Justice, of which Ford is the director, are members of the network.] This network was established by the federal government in 2001, and its centers provide public education, counseling, advocacy, and behavioral health treatment services for children and families, as well as consultation to community leaders and policymakers.

PTSD can undo a sufferer’s life. MDMA may help patients untangle their trauma and find their way back to mental health.

When lasting trauma is caused by callous acts of violence, the key to recovery can be making meaning from meaninglessness.

This year UConn Health will host a phase 3 FDA trial that tests whether the drug MDMA, known on the street as ecstasy or molly, is a safe and effective treatment for post-traumatic stress disorder. The disorder is difficult to treat, and many people have a tough time handling the treatment. MDMA not only might make therapy more tolerable but it also may help open a window for patients into their own mind. The insight allows them to process a shattering, horrific event into something that makes them stronger.

The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders defines post-traumatic stress disorder, or PTSD, as when a person is traumatized in some way and then continues to reexperience the trauma through flashbacks, nightmares, or unwanted intrusive memories. The person with PTSD avoids people or places associated with the trauma; becomes overly negative in thoughts and speech about themselves and other people; and has heightened arousal that can include a hair-trigger startle reflex, inability to sleep, hypervigilance, irritability, and aggression. At its worst, people are unable to cope with everyday life and may even become suicidal.

Often the source of the trauma is a shocking event involving interpersonal violence, such as rape, combat, or sexual abuse. Racial discrimination and harassment, particularly when it is shocking or pervasive, can also cause PTSD. UConn psychologist Monnica Williams began focusing on race-based trauma when she was at the University of Pennsylvania and had a very successful, high-achieving, black client come in with PTSD stemming from racial discrimination she’d suffered on the job. Williams was taken aback and began studying the link between racism and post-traumatic stress disorder.

Deconstructing the Trauma

But no matter what type of trauma causes the PTSD, the most effective treatment for it is exposure-based therapy, such as “prolonged exposure.” Essentially, the therapist has the patient discuss the traumatic event in excruciating detail, over and over again, until it ceases to cause overwhelming fear and anxiety.

Prolonged exposure works — indeed, it has the most evidence behind it. But it’s terribly difficult for the patients, who often get visibly upset during sessions, and many quit therapy because the experience is too much like the original trauma.

The MDMA-assisted therapy session was utterly without the distress, tension, and fear PTSD patients typically show during prolonged exposure treatment.

MDMA-assisted psychotherapy could be one way to change that. The drug stimulates the release of neurotransmitters that promote a feeling of trust and well-being and might also help the brain rewire itself. But when Williams first heard of it, she was skeptical.

“It sounded weird, like junk science, and I didn’t want to be part of that,” she says. But she agreed to take a look at an article in Psychopharmacology. She was fascinated to see that researchers had used MDMA as an adjunct to psychotherapy for PTSD and had gotten really good results. She was pleasantly surprised again when she first watched a video of an MDMA-assisted therapy session.

“People were sitting in a chair, relaxed. They’re processing it on their own, and would sometimes share new insights with the therapist,” Williams says. It was utterly unlike the distress, tension, and fear PTSD patients typically show during prolonged exposure. “They would say things like, ‘Wow. Now I understand the trauma didn’t happen to me because I’m a bad person — I was just in the wrong place at the wrong time.’ And we’re like, ‘Yes! Yes! They finally get it!’” she recalls. The MDMA helps them look at the big picture, to understand that the violence against them didn’t mean what they thought it had.

‘It’s got to come out’

It takes a while for psychoactive drugs to work their way through the FDA approval process. MAPS has been testing MDMA-assisted therapy for PTSD for more than a decade. Many of the early participants experienced lasting improvement.

Rachel Hope, who experienced a cascade of abusive events as a child that left her with severe PTSD, “did 20 years of psychotherapy” prior to participating in an MDMA-assisted therapy session. “When I got into the outer limits of the really hardcore stuff, I’d start to destabilize and get sicker … I’d start vomiting or have to leave the room. I knew that I had to tell it — the story has a soul of its own. It’s got to be seen, got to be known. It’s got to come out. But I couldn’t get it out,” she says.

Hope had had good therapists and managed to run a real estate development company, but eventually the PTSD got so bad she couldn’t leave the house. Finally her personal assistant threatened to quit if she didn’t go back into therapy. And that’s how she came to participate in an MDMA-assisted psychotherapy trial in 2005. It was a revelation.

“The MDMA was a terrific antianxiety medicine,” she says; it didn’t make her fuzzy-headed like most antianxiety meds had. “It amplified access to memories and, really, I had access to everything, and I wasn’t terrified. I could actually tell someone, for the first time in my life, what had happened to me. I had so much access to my own mind.” She describes it as the perfect tool to help work through the trauma. “I was rebooting my mind under my own directive,” Hope says.

“They would say things like, ‘Wow. Now I understand the trauma didn’t happen to me because I’m a bad person — I was just in the wrong place at the wrong time.’ And we’re like, ‘Yes! Yes! They finally get it!’”

Williams agrees that the MDMA seems to help patients rapidly make connections and breakthroughs in a single therapy session. Typically, a patient in psychotherapy might have just one such realization every few months.

The participants in the phase 3 trial at UConn Health will have a total of 20 therapy sessions, three of which will include MDMA. Each session will have two therapists present. The MDMA-assisted sessions will be six to eight hours long, after which the participant will stay overnight in the hospital to rest, supervised by a night attendant. And as part of the effort to involve participants from communities of color, all but one of the therapists at UConn Health identifies as an ethnic, racial, and/or sexual minority.

“In Singapore, I was part of the majority, but I was curious how it felt to be Malay, Indian, or one of the other minorities,” says Terence Ching, a clinical psychology doctoral student involved in the study. Ching has also lived in Australia, New Zealand, and Kentucky, where he was not part of the majority ethnic group. “That led me to critically introspect my place in society as someone with many different identities. Having that multifaceted perspective allows me to experience a lot of empathy for people from marginalized groups in the U.S.,” Ching says.

To get a better understanding of what the MDMA-assisted psychotherapy would be like for study participants, Ching participated in a session himself as part of his training.

“It felt like a lot of insights happening constantly,” Ching says. “It’s been a year since the session, and every now and then I have a moment where I remember an insight from it, and/or have another one. It’s a wonderful thing.” Ching hopes that the participants benefit from their MDMA-assisted psychotherapy in the same way he did.

“For someone who has experienced trauma, MDMA-assisted psychotherapy might help them be able to make meaning of it. I really believe in this work,” Ching says.

No matter which treatment they get, only 20 percent of young people diagnosed with anxiety will stay well over the long term, UConn Health researchers report in the Journal of the American Academy of Child and Adolescent Psychiatry.

“When you see so few kids stay non-symptomatic after receiving the best treatments we have, that’s discouraging,” says UConn Health psychologist Golda Ginsburg. She suggests that regular mental health checkups may be a better way to treat anxiety than the current model.

The study followed 319 young people aged 10 to 25 who had been diagnosed with separation, social, or general anxiety disorders at sites in California, North Carolina, Maryland, and Pennsylvania.
They received evidence-based treatment with either sertraline (the generic form of Zoloft) or cognitive behavioral therapy or a combination of the two and then had follow-ups with the researchers every year for four years.

The follow-ups assessed anxiety levels but did not provide treatment. Other studies have done a single follow-up after one, two, five, or 10 years, but those were essentially snapshots in time. This is the first study to reassess youth treated for anxiety every year for four years.

We need a different model for mental health, one that includes regular checkups.

— Golda Ginsburg, Ph.D., UConn Health Psychologist

The sequential follow-ups meant that the researchers could identify people who relapsed, recovered, and relapsed again as well as people who stayed anxious and people who stayed well. They found that 20 percent of patients got well after treatment and stayed well, rating low on anxiety at each follow-up. But about half the patients relapsed at least once, and 30 percent were chronically anxious, meeting the diagnostic criteria for an anxiety disorder at every follow-up. Females were more likely to be chronically ill than males. Other predictors of chronic illness were experiencing more negative life events, having poor family communication, and having a diagnosis of social phobia.

On the bright side, the study found that young people who responded to treatment were more likely to stay well. The study also found no difference in long-term outcomes between treatment types. This means that if there is no cognitive behavioral therapist nearby, treatment with medication is just as likely to be effective.

The study also found that kids did better if their families were supportive and had positive communication styles. Parents should talk to their child and ask the therapist questions: Why do they suggest this treatment? (It should be supported by evidence.) Have they been trained in cognitive behavioral therapy? How can we reinforce what was learned in therapy this week?

But parents should also be aware that a single intervention may not be enough.

“If we can get them well, how do we keep them well?” says Ginsburg. “We need a different model for mental health, one that includes regular checkups.”

Q&A with Nancy Petry, Ph.D., internet addiction expert

Nancy Petry’s internet addiction research is the first of its kind to be funded by the National Institutes of Health. As a member of the American Psychiatric Association’s Workgroup on Substance Use and Related Addictive Disorders, Petry led international efforts to include online gaming addiction as a condition requiring greater research in the latest version of the APA’s Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5).

Nancy Petry’s internet addiction research is the first of its kind to be funded by the National Institutes of Health. As a member of the American Psychiatric Association’s Workgroup on Substance Use and Related Addictive Disorders, Petry led international efforts to include online gaming addiction as a condition requiring greater research in the latest version of the APA’s Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5).

The explosion of our use of the internet, computers, and mobile technology is fairly new, so no one really knows the prevalence of internet or screen addiction as it hasn’t been studied nor standardly assessed. But the NIH took a significant step to begin funding my research in this area, so there soon will be insights. In December 2017, the World Health Organization announced it would be recognizing “gaming disorder” as a mental health condition in its 11th International Classification of Diseases.

Q

Who is at most risk of a gaming disorder?

Anyone, regardless of age or gender, who plays video or online games excessively may be at risk of becoming addicted. However, the most vulnerable population may be the more than 90 percent of boys ages 8 to 17 who play. While the lives of the vast majority of child gamers are not adversely impacted, about 1.5 percent of children develop significant problems when they begin to play for very long hours and forego other activities to play games. Children with a video game addiction play 3 to 8 hours daily, sometimes more.

Boys are at much greater risk than girls because they play electronic games more. Children who are more socially isolated, or have depression or attention deficit disorder (ADD) are also at greater risk. Parents should be aware of warning signs including new problems at school, trouble with or a decline in social interactions with family and friends, and a reduction in other hobbies they once enjoyed.

Q

Tell us about your novel video gaming disorder research study aiming to curb the problem.

We at UConn Health have the first NIH-funded clinical trial to help parents with their child’s video game addiction. The study tests the benefits of a family therapy approach, with one or both parents and the child participating. The children are ages 10-19 and they must have developed significant problems related to gaming. Parents are coached on how to better understand what gaming addiction is, why their child derives pleasure from the activity, and the best ways to monitor and intervene to reduce their child’s gaming. There are no other such studies in the U.S. to our knowledge, and only a handful of studies in Europe and Southeast Asia have evaluated interventions.

Q

What do you recommend to patients to curb Internet or gaming use?

Electronics are a big part of daily life, and they are not going away. It is up to each of us to limit internet or game use and make sure we, and our children, are not losing out on other things in life due to excessive use. Just like everything else, moderation is key. If you notice you or a loved one has or may become addicted to the internet or gaming, set rules such as no gaming or electronics use after 9 p.m. and start to make time for other hobbies you enjoy.

A woman who won’t drive long distances because she has panic attacks in the car. A man who has contamination fears so intense he cannot bring himself to use public bathrooms. A woman who can’t go to church because she fears enclosed spaces. All of these people have two things in common: they have an anxiety disorder, and they happen to be parents.

These parents sought help because they struggle with anxiety, and want to prevent their children from suffering the same way. Anxiety tends to run in families, with 30 to 50 percent of children of anxious parents growing up to be anxious themselves. But that does not have to be the case, according to new research by UConn Health child psychologist Golda S. Ginsburg.

Ginsburg and colleagues at Johns Hopkins University tested a one-year therapy intervention as part of a study of 136 families where at least one parent had anxiety and at least one child was between the ages of 6 and 13.

The study, published in the August issue of The American Journal of Psychiatry, found that therapy-based intervention works. Only 9 percent of children who participated in a therapist-directed intervention developed anxiety after one year, compared to 21 percent in a group that received written instruction, and 31 percent in the group that did not receive any therapy or written instruction.

Children of anxious parents have up to a 50 percent chance of growing up to be anxious themselves. But that does not have to be the case.

Both inborn temperament and life experiences play a role in whether an adult has anxiety. The more negative experiences a person has growing up, the greater the likelihood he or she will struggle with anxiety as an adult. But there is also a component of anxiety that is learned, taught inadvertently by parents who model the behavior. It’s these learned behaviors and thought patterns that interventions can help change, according to Ginsburg.

“The finding underscores the vulnerability of offspring of anxious parents,” says Ginsburg. She wants to do something about that vulnerability. “If we can identify kids at risk, let’s try and prevent this.”

Most of the adults who participated in the study struggled in school and didn’t tell anyone. They didn’t raise their hands, or they got sick before exams. They might not have had any friends. As adults, their anxiety still limits their activities and sometimes those of their family members, and they are very motivated to help their children avoid the same.

Physicians can often identify children at risk before they develop an anxiety disorder. Such kids are often hyper-aware of aches and other bodily sensations, and are frequent flyers at the doctor’s office and emergency room. For example, such a child might think “my heart is racing — I’m having a heart attack!” when a less anxious individual would think “my heart is racing because I just ran up a hill.”

Other signs of children at risk for anxiety include avoidance of school, parties, and other social situations, as well as unusual worries.

“Anxiety and fear are protective and adaptive,” says Ginsburg. “But in anxious kids they may not be, because these children have thoughts about danger and threat when there really isn’t one.”

For such a child, meeting a new peer for the first time can be paralyzing. Trying an unfamiliar food might summon worries of being poisoned. To cope with this kind of debilitating anxiety, children start avoiding whatever provokes the anxious feelings. If they’re afraid of the dark they might insist on sleeping with all the lights on. If they’re afraid of failing they won’t try new things. In extreme cases, they may refuse even to leave the house.

I’d say we need to change our model of mental health to a checkup method. Like going to the dentist every six months.

— Golda Ginsburg, Psychologist, UConn Health

One of the ways to reduce anxiety is to do a reality check. It’s a way to recognize when a fear is healthy and worth paying attention to (a growling dog) or unhealthy (a possibly poisoned birthday cake).

In the study, some of the families participated in eight, hour-long sessions with a trained therapist over a period of two months. Others were just given a pamphlet that contained general information about anxiety disorders and treatments. Still others received nothing at all.

The families who participated in therapy were taught to identify the signs of anxiety and how to reduce it. They practiced problem-solving skills, and exercised safe exposures to whatever made their child anxious.

“We taught the kids how to identify scary thoughts, and how to change them,” Ginsburg says.

If you are interested in collaborating on such a study or have patients who might benefit from a family intervention, contact Golda Ginsburg at Gginsburg@uchc.edu, or call her office at 860.523.3788.

For example, if a child is afraid of cats and encounters one in the street, the child can first identify the scary thought: “that cat is going to hurt me.” Then the child can test that thought — is it likely that cat will hurt me? No, the cat doesn’t look angry. It isn’t baring its teeth or hissing, it’s just sitting there. OK, I can walk past that cat and it won’t do anything.

In general, children who participated in the intervention had lower anxiety overall than children who did not participate in the intervention with their families.

Now the researchers have funding from the National Institutes of Health for a follow-up to see whether the effects are maintained over time. Ginsburg wonders whether there would be value in providing regular checkups for families on mental health issues. She is considering approaching insurers about offering this kind of service to families at risk, to see if it lowers their healthcare costs overall.

“I’d say we need to change our model of mental health to a checkup method,” says Ginsburg, “like going to the dentist every six months.”

Physician Spotlight

Rocio Chang, MA, Psy.D.

Psychologist

Rocio Chang is an assistant professor of psychiatry at UConn Health and an expert in childhood and adult trauma. She specializes in psychotherapy with children, adolescents, adults, and biological, foster, and adoptive families, including treatment for mood and co-occurring disorders, PTSD, and complex trauma. She is sought after to provide specific training on assessment and treatment of complex trauma, and in particular has been a resource to Latino organizations. She also serves on the clinical advisory board of several grassroots organizations, including Focus on Recovery United, GOODWorks, the Jordan Porco Foundation, and Connecticut Public Broadcasting Network.